A Phenomenological Inquiry of the Shift to Virtual Care Delivery: Insights from Front-Line Primary Care Providers.

The rapid deployment of virtual primary care visits served as a first-line response to COVID-19 and can now be examined for insights, particularly as virtual care is playing an ongoing role in patient care and consultations. Input from primary care providers directly responsible for virtual care delivery is needed to inform policies and strategies for quality care and interactions. The overarching goal of this research study was to examine the use of virtual care as a mechanism for primary healthcare delivery. A phenomenological approach investigated the shift in primary care service delivery as experienced by primary care providers and initiated during the COVID-19 pandemic. Focus groups were conducted with primary care providers (n = 21) recruited through email, advertisements, and professional organizations, exploring how virtual care was delivered, the benefits and challenges, workflow considerations, and recommendations for future use. Integrating virtual care was performed with a great deal of autonomy as well as responsibility, and overwhelmingly depended on the telephone. Technology, communication, and workflow flexibility are three key operational aspects of virtual care and its delivery. Providers highlighted cross-cutting themes related to the dynamics of virtual care including balancing risk for quality care, physician work/life balance, efficiency, and patient benefits. Primary care providers felt that virtual care options allowed increased flexibility to attend to the needs of patients and manage their practice workload, and a few scenarios were shared for when virtual care might be best suited. However, they also recognized the need to balance in-person and virtual visits, which may require guidelines that support navigating various levels of care. Overall, virtual care was considered a good addition to the whole 'care package' but continued development and refinement is an expectation for optimizing and sustaining future use.

Patients' and caregivers' experiences of virtual care in a primary care setting during the COVID-19 pandemic: A patient-oriented research study.

Objective: This study explored patient and caregiver expectations and experiences of virtual primary care in Manitoba, Canada. This study focused on accessibility of care, acceptability and perceptions of quality from 'users' of primary healthcare services. Due to the rapid implementation of virtual primary care during the COVID-19 pandemic in Canada, patient/public input was largely bypassed. Methods: A mixed method was conducted in collaboration with Patient and Caregiver Community Advisors. Data was obtained from 696 surveys and 9 focus groups (n = 41 patients and caregivers). Results: Data suggest good acceptance of virtual visits, although considered a new experience despite almost exclusive use of the telephone. Participants preferred more input for choosing the type of visit but experienced less stress, time and inconvenience by using virtual care. There were mixed opinions of quality. More complex visits were associated with incomplete consultations and serve as one exemplar of the limitations due to lack of physical presence or contact. Unique communication skills were required to convey health concerns adequately and accurately. A more transactional approach was perceived from the lack of visual cues and the awkwardness associated with pauses during the phone conversation. Virtual care may be better used for certain circumstances but should encompass patient-centred decision making for when and how. Many expressed interests in video options; technology access and user ability are additional considerations for advancing virtual care. Conclusions: The experiences and recommendations from patients and caregivers provide an important contribution to decision-making and integrating and sustaining quality virtual care for patient-centered healthcare service delivery. Keywords: Virtual care experiences, primary care, patient-oriented research, mixed methods, COVID-19.

Metabolomics revealed disruptions in amino acid and antioxidant biochemistry in Daphnia magna exposed to industrial effluents associated with plastic and polymer production.

Industrial wastewater effluents are a major source of chemicals in aquatic environments, and many of these chemicals may negatively impact aquatic life. In this study, the crustacean Daphnia magna, a common model organism in ecotoxicity studies, was exposed for 48 h to nine different industrial effluent samples from manufacturing facilities associated with the production of plastics, polymers, and coating products at a range of dilutions: 10, 25, 50, 100% (undiluted). A targeted metabolomic-based approach using liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to quantify polar metabolites from individual daphnids that survived the 48 h exposure. Multivariate analyses and metabolite changes revealed metabolic perturbations across all effluent samples studied, with non-monotonic responses and both up and downregulation relative to the unexposed control. Pathway analyses indicated the disruption of similar and distinct pathways, mostly connected to protein synthesis, amino acid metabolism, and antioxidant processes. Overall, we observed disruptions in Daphnia biochemistry that were similar across the effluent samples, but with unique features for each effluent sample. Additionally, non-monotonic heightened responses suggested additive and/or synergistic interactions between the chemicals within the industrial effluents. These findings demonstrate that targeted metabolomic approaches are a powerful tool for the biomonitoring of aquatic ecosystems in the context of complex mixtures, such as industrial wastewater effluents.

Approach to atrial fibrillation: Essentials for primary care.

OBJECTIVE: To support family physicians in preventing atrial fibrillation (AF) in patients at risk and in identifying and managing those with established AF; and to summarize key recommendations for ideal screening and care of patients. SOURCES OF INFORMATION: The 2020 Canadian Cardiovascular Society and Canadian Heart Rhythm Society comprehensive guidelines for the management of AF, based on current evidence and clinical experience related to AF. MAIN MESSAGE: Atrial fibrillation, which is estimated to affect at least 500,000 Canadians, is associated with high risks of stroke, heart failure, and death. Primary care clinicians occupy a central role in the management of this chronic condition, focusing on the challenges of preventing AF and identifying, diagnosing, treating, and following patients with AF. Evidence-based guidelines that provide optimal management strategies have been published by the Canadian Cardiovascular Society and Canadian Heart Rhythm Society to assist in these tasks. Messages critical to primary care are offered to support effective knowledge translation. CONCLUSION: Most patients with AF can be managed effectively in primary care. Family physicians not only play an important role in ensuring patients with AF receive timely diagnoses, but they are also key to providing initial and ongoing care, especially in patients with comorbid conditions.

Daphnia magna sub-lethal exposure to phthalate pollutants elicits disruptions in amino acid and energy metabolism.

Phthalic acid esters (PAEs) are a class of chemicals that are usually incorporated as additives in the manufacturing of plastics. PAEs are not covalently bound to the material matrix and can, consequently, be leached into the environment. PAEs have been reported to act as endocrine disruptors, neurotoxins, metabolic stressors, and immunotoxins to aquatic organisms but there is a lack of information regarding the impact of sub-lethal concentrations to target organisms. The freshwater crustacean Daphnia magna, a commonly used model organism in aquatic toxicity, was exposed to four phthalate pollutants: dimethyl phthalate (DMP), diethyl phthalate (DEP), monomethyl phthalate (MMP), and monoethyl phthalate (MEP). Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was employed in a targeted metabolomic approach to quantify polar metabolites extracted from a single Daphnia body. Individual metabolite percent changes and hierarchical clustering heatmap analysis showed unique metabolic profiles for each phthalate pollutant. Metabolite percent changes were mostly downregulated or presented opposing responses for the low and high concentrations tested. Meanwhile, pathway analyses suggest the disruption of related and unique pathways, mostly connected with amino acid and energy metabolism. The pathways aminoacyl-tRNA biosynthesis, arginine biosynthesis, and glutathione metabolism were disrupted by most selected PAEs. Overall, this study indicates that although phthalate pollutants can elicit distinct metabolic perturbations to each PAE, they still impacted related biochemical pathways. These chemical-class based responses could be associated with a common toxic mechanism of action. The reported findings show how targeted metabolomic approaches can lead to a better understanding of sub-lethal exposure to pollutants, revealing metabolomic endpoints do not hold a close relationship with traditional acute toxicity endpoints.

Sublethal Exposure of Per- and Polyfluoroalkyl Substances of Varying Chain Length and Polar Functionality Results in Distinct Metabolic Responses in Daphnia magna.

Per- and polyfluoroalkyl substances (PFAS) are a class of persistent organic pollutants used in industrial applications because of their physicochemical properties, which results in their ubiquitous presence across environmental matrices. To date, legacy PFAS have been well studied; however, the concentration of alternative PFAS may exceed the concentration of legacy pollutants, and more information is needed regarding the sublethal toxicity at the molecular level of aquatic model organisms, such as Daphnia magna. Perfluorobutanoic acid (PFBA), perfluorohexanoic acid (PFHxA), perfluorohexanesulfonic acid (PFHxS), and perfluorononanoic acid (PFNA) are four widely detected PFAS alternatives of varying chain length and polar functionality that are quantified in aquatic environments. The present study examines the metabolic perturbations of PFAS with varying chemistries to D. magna using targeted mass spectrometry-based metabolomics. Daphnia were acutely exposed to sublethal concentrations of PFBA, PFHxA, PFHxS, and PFNA before the polar metabolite profile was extracted from single organisms. Multivariate analysis demonstrated significant separation between the sublethal concentrations of PFHxA, PFHxS, and PFNA relative to the controls; in sum, longer chain lengths demonstrated greater overall perturbations to the extracted metabolic profiles. Univariate statistics revealed significant perturbations in the concentrations of several amino acids, nucleotides/nucleosides, and neurotransmitters with exposure to PFAS. These metabolic perturbations are consistent with disruptions in energy metabolism (pantothenate and coenzyme A metabolism, histidine metabolism) and protein synthesis (aminoacyl-transfer RNA biosynthesis and amino acid metabolism), which were identified through biochemical pathway analysis. These results provide evidence that although PFAS chemistry (chain length and polar functional group) invokes unique metabolic responses, there is also an underlying toxic mode of action that is common with select PFAS exposure. Overall, the present study highlights the capabilities of environmental metabolomics to elucidate the molecular-level perturbations of pollutants within the same chemical class to model aquatic organisms, which can be used to prioritize risk assessment of substituted PFAS alternatives. Environ Toxicol Chem 2023;42:242-256. © 2022 SETAC.

Characterizing the use of virtual care in primary care settings during the COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: In March 2020, Canada implemented restrictions to curb viral transmission of COVID-19, which resulted in abrupt disruptions to conventional (in-person) clinical care. To retain continuity of care the delivery of primary care services shifted to virtual care. This study examined the nature of virtual visits, characterizing the use and users of virtual care in primary care settings from March 14/20 to June 30/20 of the COVID-19 pandemic.  METHODS: Retrospective cohort study of primary care providers in Manitoba, Canada that participate in the Manitoba Primary Care Research Network (MaPCReN) and offered ≥ 1 virtual care visit between 03/14/20 and 06/30/20 representing 142,616 patients. Tariff codes from billing records determined the visit type (clinic visit, virtual care). Between 03/14/20, and 06/30/20, we assessed each visit for a follow-up visit between the same patient and provider for the same diagnosis code. Patient (sex, age, comorbidities, visit frequency, prescriptions) and provider (sex, age, clinic location, provider type, remuneration, country of graduation, return visit rate) characteristics describe the study population by visit type. Generalized estimating equation models describe factors associated with virtual care.  RESULTS: There were 146,372 visits provided by 154 primary care providers between 03/14/20 and 06/30/20, of which 33.6% were virtual care. Female patients (OR 1.16, CI 1.09-1.22), patients with ≥ 3 comorbidities (OR 1.71, CI 1.44-2.02), and patients with ≥ 10 prescriptions (OR 2.71, 2.2-1.53) had higher odds of receiving at least one virtual care visit compared to male patients, patients with no comorbidities and patients with no prescriptions. There was no significant difference between the number of follow-up visits that were provided as a clinic visit compared to a virtual care visit (8.7% vs. 5.8%) (p = 0.6496). CONCLUSION: Early in the pandemic restrictions, approximately one-third of visits were virtual. Virtual care was utilized by patients with more comorbidities and prescriptions, suggesting that patients with chronic disease requiring ongoing care utilized virtual care. Virtual care as a primary care visit type continues to evolve. Ongoing provision of virtual care can enhance quality, patient-centered care moving forward.

Protective effects of prior third dose mRNA vaccination in rural nursing home residents during SARS-CoV-2 outbreaks.

BACKGROUND: In Canada, mortality due to SARS-CoV-2 disproportionately impacted residents of nursing homes (NH). In November 2021, NH residents in the Canadian province of Manitoba became eligible to receive three doses of mRNA vaccine but coverage with three doses has not been universal. The objective of this study was to compare the protection from infection conferred by one, two, and three doses of COVID-19 mRNA vaccine compared to no vaccination among residents of nursing homes experiencing SARS-CoV-2 outbreaks. METHODS: Infection Prevention and Control reports from 8 rural nursing homes experiencing outbreaks of SARS-CoV-2 between January 6, 2022, and March 5, 2022, were analyzed. Attack rates and the number needed to vaccinate (NNV) were calculated. RESULTS: SARS-CoV-2 attack rate was 65% among NH residents not vaccinated, 58% among residents who received 1-2 doses of mRNA COVID-19 vaccine, and 28% among residents who had received 3 vaccine doses. The NNV to prevent one nursing home resident from SARS-CoV-2 infection during an outbreak was 3 for a vaccination with 3 doses and 14 for 1-2 doses of COVID-19 mRNA vaccine. The superiority of receiving the third dose was statistically significant compared to 1-2 doses (Chi-Squared, p < 0.00001). CONCLUSIONS: Nursing home residents who received three doses of COVID-19 mRNA vaccine were at lower risk of SARS-CoV-2 infection compared to those who received 1-2 doses. Our analyses lend support to the protective effects of the third dose of mRNA vaccine for NH residents in the event of a SARS-CoV-2 outbreak.

Primary medication nonadherence in a large primary care population: Observational study from Manitoba.

OBJECTIVE: To analyze primary medication nonadherence across several prescription indications and test the predictors of drug nonadherence in an adult primary care population. DESIGN: Retrospective observational study using primary care provider prescriptions linked to pharmacy-based dispensing data from 2012 to 2014. SETTING: Manitoba. PARTICIPANTS: Patients in the Manitoba Primary Care Research Network. MAIN OUTCOME MEASURES: Prevalence of primary medication nonadherence by drug class. Multivariable logistic regression models were used to test the associations of patient demographic and clinical or provider characteristics with primary medication nonadherence. The C statistic was used to assess the models' discriminative performance. RESULTS: A total of 91,660 unique prescriptions were assessed from a cohort of more than 200,000 patients. Primary medication nonadherence ranged from 13.7% (antidepressants) to 30.3% (antihypertensives). In conditions that typically present symptomatically (eg, infections, anxiety) nonadherence ranged from 13.7% to 17.5%. The range was 21.2% to 30.0% for medications related to asymptomatic conditions or those typically detected by screening. The discriminative performance of the models based on patient demographic, clinical, or provider characteristics was weak. CONCLUSION: Primary medication nonadherence is common, occurring more often in asymptomatic conditions. The poor predictability of the models suggests that caution is required when considering characteristic-based interventions or prediction tools to improve primary medication nonadherence.

Metabolomic analysis predicted changes in growth rate in Daphnia magna exposed to acetaminophen.

As urbanization and the global population increases, pollutants associated with municipal wastewater such as pharmaceuticals are becoming more prevalent in aquatic environments. Acetaminophen (paracetamol) is a widely used drug worldwide and one of the most frequently detected pharmaceuticals in freshwater ecosystems. This study investigated the impact of acetaminophen on the metabolite profile of Daphnia magna at two life stages; and used these metabolomic findings to hypothesize a potential impact at a higher organismal level which was subsequently tested experimentally. Targeted polar metabolite analysis by liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to measure changes in the concentration of 51 metabolites in the neonate (> 24 h old) and adult (8 day-old) daphnids following a 48-h exposure to sub-lethal concentrations of acetaminophen. The impact of acetaminophen on the metabolic profile of neonates was widely different from adults. Also, acetaminophen exposure perturbed the abundance of nucleotides more extensively than other metabolites. The acute metabolomic experimental results led to the hypotheses that exposure to sub-lethal concentrations of acetaminophen upregulates protein synthesis in D. magna and subsequently increases growth during early life stages and has an opposite impact on adults. Accordingly, a 10 day growth rate experiment indicated that exposure to acetaminophen elevated biomass production in neonates but not in adults. These novel findings demonstrate that a targeted analysis and interpretation of the changes in the polar metabolic profile of organisms in response to environmental stressors could be used as a tool to predict changes at higher biological levels. As such, this study further emphasizes the incorporation of molecular-level platforms as critical and robust tools in environmental assessment frameworks and biomonitoring of aquatic ecosystems.

Comparison of sub-lethal metabolic perturbations of select legacy and novel perfluorinated alkyl substances (PFAS) in Daphnia magna.

Per- and polyfluoroalkyl substances (PFAS) are a class of pollutants of concern due to their ubiquitous presence, persistence, and toxicity in aquatic environments. Legacy PFAS pollutants such as perfluorooctanesulfonic acid (PFOS) and perfluorooctanoic acid (PFOA) have been more widely studied in aquatic environments. However, replacement PFAS, such as ammonium perfluoro (2-methyl-3-oxahexanoate; GenX) are increasingly being detected with little known information surrounding their toxicity. Here, Daphnia magna, a model organism for freshwater ecotoxicology was used to compare the acute sub-lethal toxicity of PFOS, PFOA, GenX, and PFAS mixtures. Using liquid chromatography with tandem mass spectrometry (LC-MS/MS), the targeted polar metabolic profile extracted from single Daphnia was quantified to investigate perturbations in the exposure groups versus the unexposed organisms. Multivariate statistical analyses demonstrated significant non-monotonic separation in PFOA, GenX, and PFAS mixture exposures. Sub-lethal exposure to concentrations of PFOS did not lead to significant separation in multivariate analyses. Univariate statistics and pathway analyses were used to elucidate the mode of action of PFAS exposure. Exposure to all individual PFAS led to significant perturbations in many amino acids including cysteine, histidine, tryptophan, glycine, and serine. These perturbations are consistent with biochemical pathway disruptions in the pantothenate and Coenzyme A (CoA) biosynthesis, thiamine metabolism, histidine metabolism, and aminoacyl-tRNA biosynthesis pathways. Overall, the collected metabolomic data is consistent with disruptions in energy metabolism and protein synthesis as the primary mode of action of sub-lethal PFAS exposure. Secondary modes of action among individual pollutant exposures demonstrated that the structural properties (carboxylic acid vs. sulfonic acid group) may play a role in the metabolic perturbations observed. Sub-lethal exposure to PFAS mixtures highlighted a mixed response when compared to the individual pollutants (PFOS, PFOA, and GenX). Overall, this study emphasizes the niche capability of environmental metabolomics to differentiate secondary modes of action from metabolic perturbations in both single pollutant and pollutant mixtures within the same chemical class.

Metabolomics Reveals That Bisphenol Pollutants Impair Protein Synthesis-Related Pathways in Daphnia magna.

Bisphenols are used in the production of polycarbonate plastics and epoxy resins. Bisphenol A (BPA) has been widely studied and is believed to act as an endocrine disruptor. Bisphenol F (BPF) and bisphenol S (BPS) have increasingly been employed as replacements for BPA, although previous studies suggested that they yield similar physiological responses to several organisms. Daphnia magna is a common model organism for ecotoxicology and was exposed to sub-lethal concentrations of BPA, BPF, and BPS to investigate disruption to metabolic profiles. Targeted metabolite analysis by liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to measure polar metabolites extracted from D. magna, which are linked to a range of biochemical pathways. Multivariate analyses and individual metabolite changes showed similar non-monotonic concentration responses for all three bisphenols (BPA, BPF, and BPS). Pathway analyses indicated the perturbation of similar and distinct pathways, mostly associated with protein synthesis, amino acid metabolism, and energy metabolism. Overall, we observed responses that can be linked to a chemical class (bisphenols) as well as distinct responses that can be related to each individual bisphenol type (A, F, and S). These findings further demonstrate the need for using metabolomic analyses in exposure assessment, especially for chemicals within the same class which may disrupt the biochemistry uniquely at the molecular-level.

Patient values and preferences on polypharmacy and deprescribing: a scoping review.

Background Understanding how patient values and preferences towards polypharmacy and deprescribing have been studied is important to gain insight on current knowledge in this area and to identify knowledge gaps. Aim To describe methods and outcomes for studying patient values and preferences towards polypharmacy and deprescribing, and to identify gaps in the existing literature. Method A scoping review was conducted on English-language studies that examined patient preferences and values related to polypharmacy and/or deprescribing among community-dwelling adults. MEDLINE, Embase, PubMed, PsycINFO, EconLit, Social Science Citation Index, Science Citation Index Expanded, International Pharmaceutical Abstracts, and CINAHL/AgeLine were searched. Results Thirty articles were included. Surveys (n = 17, 56.7%), interviews/focus groups (n = 9, 30.0%), and mixed methods (n = 3, 10.0%), were commonly used methods. Patients Attitudes Towards Deprescribing (PATD) was the most common tool used (n = 9, 30.0%). Twelve themes related to attitudes, social pressure, and control of polypharmacy/deprescribing were identified. The most frequently-encountered themes included desire or willingness to reduce medication load and influence of healthcare provider on medication use. Conclusion PATD was commonly used to assess preferences and values towards polypharmacy and limited knowledge on patient-important outcomes were addressed. Future research should focus on shared decision-making and communicating risk versus benefit of medications.

Primary prescription adherence for obstructive lung disease in a primary care population.

BACKGROUND: The objective of this study was to determine primary prescription adherence for obstructive lung diseases (e.g., asthma, COPD) in an adult primary care patient population over a 3-year period. METHODS: A retrospective analysis of electronic medical record and administrative data was performed to determine primary adherence, defined as dispensation of a new prescription within 90 days of the date the prescription was written. Multivariable logistic regression models were used to test predictors of prescription primary adherence. RESULTS: Of 13,220 prescriptions for obstructive airway disease, 75.9% (N = 10,038) were filled. In multivariate analysis, depression, certain age groups (18-44 years), higher income quartile were associated with reduced prescription adherence. However, 1-2 ER visits in the previous year (compared to no ER visits), number of ambulatory visits in the previous year, and number of hospitalizations in the previous year, did not increase the likelihood of prescription adherence. INTERPRETATION: This study provides important insights about factors associated with prescription nonadherence and is the first study examining primary medication adherence with medications for obstructive lung disease in adults, providing indications of prescription nonadherence patterns among a broad population.

Targeted Metabolomic Assessment of the Sub-Lethal Toxicity of Halogenated Acetic Acids (HAAs) to Daphnia magna.

Halogenated acetic acids (HAAs) are amongst the most frequently detected disinfection by-products in aquatic environments. Despite this, little is known about their toxicity, especially at the molecular level. The model organism Daphnia magna, which is an indicator species for freshwater ecosystems, was exposed to sub-lethal concentrations of dichloroacetic acid (DCAA), trichloroacetic acid (TCAA) and dibromoacetic acid (DBAA) for 48 h. Polar metabolites extracted from Daphnia were analyzed using liquid chromatography hyphened to a triple quadrupole mass spectrometer (LC-MS/MS). Multivariate analyses identified shifts in the metabolic profile with exposure and pathway analysis was used to identify which metabolites and associated pathways were disrupted. Exposure to all three HAAs led to significant downregulation in the nucleosides: adenosine, guanosine and inosine. Pathway analyses identified perturbations in the citric acid cycle and the purine metabolism pathways. Interestingly, chlorinated and brominated acetic acids demonstrated similar modes of action after sub-lethal acute exposure, suggesting that HAAs cause a contaminant class-based response which is independent of the type or number of halogens. As such, the identified metabolites that responded to acute HAA exposure may serve as suitable bioindicators for freshwater monitoring programs.

Using Information Technology to Assess Patient Risk Factors in Primary Care Clinics: Pragmatic Evaluation.

BACKGROUND: Tobacco use, physical inactivity, and poor diet are associated with morbidity and premature death. Health promotion and primary prevention counseling, advice, and support by a primary care provider lead to behavior change attempts among patients. However, although physicians consider preventative health important, there is often a larger focus on symptom presentation, acute care, and medication review. OBJECTIVE: This study evaluated the feasibility, adoption, and integration of the tablet-based Risk Factor Identification Tool (RFIT) that uses algorithmic information technology to support obtainment of patient risk factor information in primary care clinics. METHODS: This is a pragmatic developmental evaluation. Each clinic developed a site-specific implementation plan adapted to their workflow. The RFIT was implemented in 2 primary care clinics located in Manitoba. Perceptions of 10 clinic staff and 8 primary care clinicians informed this evaluation. RESULTS: Clinicians reported a smooth and fast transfer of RFIT responses to an electronic medical record encounter note. The RFIT was used by 207 patients, with a completion rate of 86%. Clinic staff reported that approximately 3%-5% of patients declined the use of the RFIT or required assistance to use the tablet. Among the 207 patients that used the RFIT, 22 (12.1%) smoked, 39 (21.2%) felt their diet could be improved, 20 (12.0%) reported high alcohol consumption, 103 (56.9%) reported less than 150 minutes of physical activity a week, and 6 (8.2%) patients lived in poverty. Clinicians suggested that although a wide variety of patients were able to use the tablet-based RFIT, implemented surveys should be tailored to patient subgroups. CONCLUSIONS: Clinicians and clinic staff positively reviewed the use of information technology in primary care. Algorithmic information technology can collect, organize, and synthesize individual health information to inform and tailor primary care counseling to the patients' context and readiness to change. The RFIT is a user-friendly tool that provides an effective method for obtaining risk factor information from patients. It is particularly useful for subsets of patients lacking continuity in the care they receive. When implemented within a context that can support practical interventions to address identified risk factors, the RFIT can inform brief interventions within primary care.

Closing the gap in postfracture care at the population level: a randomized controlled trial.

BACKGROUND: Postfracture care is suboptimal, and strategies to address this major gap in care are necessary. We investigated whether notifications sent by mail to physicians and patients would lead to improved postfracture care. METHODS: We conducted a randomized controlled trial (ClinicalTrials.gov identifier NCT00594789) in the province of Manitoba, Canada, from June 2008 to May 2010. Using medical claims data, we identified 4264 men and women age 50 years or older who recently reported major fractures, and who had not undergone recent bone mineral density testing or treatment for osteoporosis. Participants were randomized to three groups: group 1 received usual care (n = 1480), patients in group 2 had mailed notification of the fracture sent to their primary care physicians (n = 1363), and group 3 had notifications sent to both physicians and patients (n = 1421). Bone mineral density testing and the start of pharmacologic treatment for osteoporosis within the following 12 months were documented. RESULTS: Among participants in group 1 (usual care), 15.8% of women and 7.6% of men underwent testing for bone mineral density or started pharmacologic treatment for osteoporosis. Outcome measures improved among participants in group 2 (30.3% of women and 19.0% of men, both p < 0.001) and group 3 (34.0% of women and 19.8% of men, both p < 0.001). No additional benefit was seen with patient notification in addition to physician notification. Combining groups 2 and 3, the absolute increase for the combined end point of bone mineral density testing or pharmacologic treatment was 14.9% (16.4% among women, 11.8% among men). The number needed to notify to change patient care was 7 (6 for women, 6 for men). The adjusted odds ratio (OR) to change patient care in group 2 was 2.45 (95% confidence interval [CI] 2.01-2.98); for group 3 the OR was 2.82 (95% CI 2.33-3.43). INTERPRETATION: This notification system provides a relatively simple way to enhance post-fracture care.

Closing the postfracture care gap using administrative health databases: design and implementation of a randomized controlled trial.

Postfracture care is suboptimal, and strategies to address this major care gap are urgently required. Case management is effective but is resource intensive and difficult to deliver to a widely scattered population. We describe the design and successful implementation of a randomized controlled trial (NCT00594789), which uses provincial administrative health databases to notify eligible physicians and patients after a major osteoporotic fracture that such fractures warrant additional assessment or pharmacologic treatment to prevent subsequent fractures. Men and women aged 50 yr or older residing in the Province of Manitoba, Canada, with a recently reported clinical fracture (hip, spine, humerus, and forearm) from medical claims data, and without recent bone mineral density (BMD) testing (in the last 3 yr) or osteoporosis therapy (in the last year), were randomized to 3 groups: group 1 received usual care, group 2 (physicians only) had mailed notification to the primary care physicians (alert letter, BMD requisition, and management flowchart), and group 3 (physicians and patient) had both physician notifications and patient notification (alert letter). During the initial 10 mo (from June 2008 to March 2009), 2901 fracture patients meeting the inclusion criteria were randomized. Groups were well balanced. Direct costs related to the initiative (programming, case identification, and mailings) were Canadian dollars (CAD$)12,379 during the pilot phase, which translates to CAD$6.50 per notification (groups 2 and 3). Ongoing costs (which exclude the initial programming costs) are estimated at CAD$1.25 per notification. This postfracture intervention, based on medical claims data, provides an easy way to enhance postfracture care. The approach is scalable, can be delivered to a widely scattered population, and requires minimal infrastructure. This low-cost intervention may complement more resource-intensive programs based on case managers.